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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD <br /> 561365 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> 1 i r <br /> i I W t .USE ❑ Heating/Cooling <br /> _ �_ �_ X 17 Domestic ❑ Monitoring <br /> W i I E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> ' T [ITest Well ❑ Dewatering ❑ Remedial <br /> I i <br /> r-mi. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> r 1 <br /> I 1 mitr j L7 Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME n.to ft. lbs./ft. n:t5 ft. <br /> X2"7'?' GT?2(il"4i in.to ft. —_-__--- lbs./ft. _m to ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make_ ,` a' u'`- '(Dn from ft.to ft. <br /> Type _ inles�> Sf-e''_j Diam. <br /> Slot/Gauze i Length +' t <br /> r <br /> Set between _ft.and 1; _ ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF <br /> RDNESSOF FROM TO ft. Ll below ❑ above land surface Date measured <br /> MATERIALPUMPING LEVEL(below land surface) <br /> ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> L7 Pitless adapter manufacturer - Model <br /> ❑ Casing Protection __ El 12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? O.Yes ❑ No <br /> i Grout Material ❑ Neat cement q- <br /> ,Bentonite <br /> from to ft. ❑ yds-® bags <br /> from to ft. _ ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOW_ N SOURCE OF CONTAMINATION _ <br /> feet /G IQ direction e7'iC type <br /> Well disinfected upon completion? Q Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> Manufacturer's name <br /> Model number T T_ HP Volts <br /> Length of drop pipe i ft. Capacity __g.p.m. <br /> Pressure Tank Capacity ',� 'i': i`, _ <br /> Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes O No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed D00 :?'r1(-V Td, IYEH.a DRILLING CO. f - <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee BusinessNameLic.or Reg.No. <br /> Authorized Rhe-prresentative Signature Date <br /> Name of Driller Date <br /> LOCAL COPY 561365 HE-01205-04(Rev.5/92) <br />